I’ve put CPAP on probably 200+ patients at this point. Failed miserably on my first dozen. Now? Maybe 1 in 20 won’t tolerate it. Here’s what changed.
1. Coach Before You Strap
Biggest mistake I see? Slapping the mask on a panicking patient. Stop. Take 30 seconds. Show them the mask. Let them hold it to their own face first. Say this:
“This is going to feel weird for about 60 seconds. Like sticking your head out a car window. Then your body figures it out and it gets easier. I’ll coach you through it.”
That prep talk? Game changer. Sets expectations. Reduces the freak-out factor by 80%.
2. Start Low, Go Slow (Sometimes)
Textbook says start at 5, titrate up. Real world? Depends.
- CHF patients: Start at 7.5-10. They need the pressure. They’ll thank you in 5 minutes.
- COPD/anxious patients: Start at 5. Let them adjust. Creep up.
- Drowning (pulmonary edema): Hit them with 10+ right away. No time for gentle.
3. The Head Tilt Trick
Patient fighting it? Won’t seal? Try this: Slight head tilt back (not full head-tilt chin-lift, just a bit). Opens the airway, reduces the feeling of suffocation, improves seal. Learned this from an RT at VGH. Works almost every time.
4. Talk Them Through the First Two Minutes
Don’t strap and abandon. Stay there. Coach their breathing:
“In through your nose… out through your mouth… perfect… in through your nose… let the machine help… that’s it…”
Boring? Yes. Effective? Absolutely. Most CPAP failures happen in the first 2 minutes. Stay engaged.
5. Know When to Pivot
Real talk: Some patients won’t tolerate it. Period. Signs it’s not working:
- Declining LOC (they’re tiring out)
- Vomiting (immediate mask removal, obviously)
- Increasing agitation after 3-4 minutes (not initial panic)
- No improvement after 10 minutes at adequate pressure
Don’t ride a dead horse. BVM is always there. RSI exists for a reason.
Bonus Tip: The Leak is Usually the Nose
Mask leaking? Everyone tightens the bottom straps. Wrong move. The leak is almost always at the bridge of the nose. Adjust top straps first. Pull mask slightly away from face, resettle it, then tighten TOP straps. Bottom straps just need to be snug, not tight.
What Success Looks Like
You’ll know it’s working when:
- Work of breathing decreases (watch those accessories relax)
- O2 sats climb (duh)
- They stop looking terrified
- Skin color improves (that grey/blue tinge fades)
- They can speak in fuller sentences
Usually takes 5-10 minutes for full effect. Be patient.
Final Thought
CPAP is magic when it works. But it’s not just about the pressure settings – it’s about the approach. Calm patient = successful CPAP. Panicked patient = failed CPAP.
Your demeanor sets the tone. Be confident. Be calm. Coach them through it.
– Keep crushing it